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Malmborg M, Assad Turky Al-Kahwa A, Kober L, Torp-Pedersen C, Butt JH, Zahir D, Tuxen CD, Poulsen MK, Madelaire C, Fosbol E, Gislason G, Hildebrandt P, Andersson C, Gustafsson F, Schou M. Specialized heart failure clinics versus primary care: Extended registry-based follow-up of the NorthStar trial. PLoS One 2023; 18:e0286307. [PMID: 37289772 PMCID: PMC10249840 DOI: 10.1371/journal.pone.0286307] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Whether continued follow-up in specialized heart failure (HF) clinics after optimization of guideline-directed therapy improves long-term outcomes in patients with HF with reduced ejection fraction (HFrEF) is unknown. METHODS AND RESULTS 921 medically optimized HFrEF patients enrolled in the NorthStar study were randomly assigned to follow up in a specialized HF clinic or primary care and followed for 10 years using Danish nationwide registries. The primary outcome was a composite of HF hospitalization or cardiovascular death. We further assessed the 5-year adherence to prescribed neurohormonal blockade in 5-year survivors. At enrollment, the median age was 69 years, 24,7% were females, and the median NT-proBNP was 1139 pg/ml. During a median follow-up time of 4.1 (Q1-Q3 1.5-10.0) years, the primary outcome occurred in 321 patients (69.8%) randomized to follow-up in specialized HF clinics and 325 patients (70.5%) randomized to follow-up in primary care. The rate of the primary outcome, its individual components, and all-cause death did not differ between groups (primary outcome, hazard ratio 0.96 [95% CI, 0.82-1.12]; cardiovascular death, 1.00 [0.81-1.24]; HF hospitalization, 0.97 [0.82-1.14]; all-cause death, 1.00 [0.83-1.20]). In 5-year survivors (N = 660), the 5-year adherence did not differ between groups for angiotensin-converting enzyme inhibitors (p = 0.78), beta-blockers (p = 0.74), or mineralocorticoid receptor antagonists (p = 0.47). CONCLUSIONS HFrEF patients on optimal medical therapy did not benefit from continued follow-up in a specialized HF clinic after initial optimization. Development and implementation of new monitoring strategies are needed.
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Affiliation(s)
| | | | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jawad H. Butt
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Deewa Zahir
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Hellerup, Denmark
| | - Christian D. Tuxen
- Department of Cardiology, Bispebjerg-Frederiksberg Hospital, Frederiksberg, DK, Denmark
| | - Mikael K. Poulsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Christian Madelaire
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Hellerup, Denmark
| | - Emil Fosbol
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Gunnar Gislason
- Danish Heart Foundation, Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Per Hildebrandt
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
- Frederiksberg Heart Clinic, Frederiksberg, Denmark
| | - Charlotte Andersson
- Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States of America
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Hellerup, Denmark
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McLellan J, Heneghan CJ, Perera R, Clements AM, Glasziou PP, Kearley KE, Pidduck N, Roberts NW, Tyndel S, Wright FL, Bankhead C. B-type natriuretic peptide-guided treatment for heart failure. Cochrane Database Syst Rev 2016; 12:CD008966. [PMID: 28102899 PMCID: PMC5449577 DOI: 10.1002/14651858.cd008966.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Heart failure is a condition in which the heart does not pump enough blood to meet all the needs of the body. Symptoms of heart failure include breathlessness, fatigue and fluid retention. Outcomes for patients with heart failure are highly variable; however on average, these patients have a poor prognosis. Prognosis can be improved with early diagnosis and appropriate use of medical treatment, use of devices and transplantation. Patients with heart failure are high users of healthcare resources, not only due to drug and device treatments, but due to high costs of hospitalisation care. B-type natriuretic peptide levels are already used as biomarkers for diagnosis and prognosis of heart failure, but could offer to clinicians a possible tool to guide drug treatment. This could optimise drug management in heart failure patients whilst allaying concerns over potential side effects due to drug intolerance. OBJECTIVES To assess whether treatment guided by serial BNP or NT-proBNP (collectively referred to as NP) monitoring improves outcomes compared with treatment guided by clinical assessment alone. SEARCH METHODS Searches were conducted up to 15 March 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (OVID), Embase (OVID), the Database of Abstracts of Reviews of Effects (DARE) and the NHS Economic Evaluation Database in the Cochrane Library. Searches were also conducted in the Science Citation Index Expanded, the Conference Proceedings Citation Index on Web of Science (Thomson Reuters), World Health Organization International Clinical Trials Registry and ClinicalTrials.gov. We applied no date or language restrictions. SELECTION CRITERIA We included randomised controlled trials of NP-guided treatment of heart failure versus treatment guided by clinical assessment alone with no restriction on follow-up. Adults treated for heart failure, in both in-hospital and out-of-hospital settings, and trials reporting a clinical outcome were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and evaluated risk of bias. Risk ratios (RR) were calculated for dichotomous data, and pooled mean differences (MD) (with 95% confidence intervals (CI)) were calculated for continuous data. We contacted trial authors to obtain missing data. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table. MAIN RESULTS We included 18 randomised controlled trials with 3660 participants (range of mean age: 57 to 80 years) comparing NP-guided treatment with clinical assessment alone. The evidence for all-cause mortality using NP-guided treatment showed uncertainty (RR 0.87, 95% CI 0.76 to 1.01; patients = 3169; studies = 15; low quality of the evidence), and for heart failure mortality (RR 0.84, 95% CI 0.54 to 1.30; patients = 853; studies = 6; low quality of evidence).The evidence suggested heart failure admission was reduced by NP-guided treatment (38% versus 26%, RR 0.70, 95% CI 0.61 to 0.80; patients = 1928; studies = 10; low quality of evidence), but the evidence showed uncertainty for all-cause admission (57% versus 53%, RR 0.93, 95% CI 0.84 to 1.03; patients = 1142; studies = 6; low quality of evidence).Six studies reported on adverse events, however the results could not be pooled (patients = 1144; low quality of evidence). Only four studies provided cost of treatment results, three of these studies reported a lower cost for NP-guided treatment, whilst one reported a higher cost (results were not pooled; patients = 931, low quality of evidence). The evidence showed uncertainty for quality of life data (MD -0.03, 95% CI -1.18 to 1.13; patients = 1812; studies = 8; very low quality of evidence).We completed a 'Risk of bias' assessment for all studies. The impact of risk of bias from lack of blinding of outcome assessment and high attrition levels was examined by restricting analyses to only low 'Risk of bias' studies. AUTHORS' CONCLUSIONS In patients with heart failure low-quality evidence showed a reduction in heart failure admission with NP-guided treatment while low-quality evidence showed uncertainty in the effect of NP-guided treatment for all-cause mortality, heart failure mortality, and all-cause admission. Uncertainty in the effect was further shown by very low-quality evidence for patient's quality of life. The evidence for adverse events and cost of treatment was low quality and we were unable to pool results.
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Affiliation(s)
- Julie McLellan
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Carl J Heneghan
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Alison M Clements
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Karen E Kearley
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nicola Pidduck
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Sally Tyndel
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - F Lucy Wright
- University of OxfordCancer Epidemiology Unit, Nuffield Department of Population HealthRichard doll BldgOld Road Campus, Roosevelt DriverOxfordUKOX3 7LF
| | - Clare Bankhead
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Schou M, Gislason G, Videbaek L, Kober L, Tuxen C, Torp-Pedersen C, Hildebrandt PR, Gustafsson F. Effect of extended follow-up in a specialized heart failure clinic on adherence to guideline recommended therapy: NorthStar Adherence Study. Eur J Heart Fail 2014; 16:1249-55. [DOI: 10.1002/ejhf.176] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/22/2014] [Accepted: 08/28/2014] [Indexed: 01/08/2023] Open
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Cleland JG, Coletta AP, Freemantle N, Clark AL. Clinical trials update from the American College of Cardiology Meeting 2011: STICH, NorthStar, TARGET, and EVEREST II. Eur J Heart Fail 2014; 13:805-8. [DOI: 10.1093/eurjhf/hfr077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John G.F. Cleland
- Department of Cardiology; Hull York Medical School, Castle Hill Hospital, University of Hull; Daisy Building Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Alison P. Coletta
- Department of Cardiology; Hull York Medical School, Castle Hill Hospital, University of Hull; Daisy Building Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Nick Freemantle
- Department of Primary Care and Population Health; UCL Medical School; Rowland Hill Street London NW3 2PF UK
| | - Andrew L. Clark
- Department of Cardiology; Hull York Medical School, Castle Hill Hospital, University of Hull; Daisy Building Cottingham Kingston-upon-Hull HU16 5JQ UK
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Affiliation(s)
- Tiny Jaarsma
- Department of Social and Welfare Studies; Faculty of Health Sciences Linköping University; Norrköping Sweden
| | - Marie Louise Luttik
- Department of Cardiology; University Medical Centre Groningen, University of Groningen; Groningen The Netherlands
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Schou M, Gustafsson F, Videbaek L, Andersen H, Toft J, Nyvad O, Ryde H, Fog L, Jensen JCH, Nielsen OW, Lind-Rasmussen S, Abdulla J, Hildebrandt PR. Adding serial N-terminal pro brain natriuretic peptide measurements to optimal clinical management in outpatients with systolic heart failure: a multicentre randomized clinical trial (NorthStar monitoring study). Eur J Heart Fail 2013; 15:818-27. [PMID: 23507787 DOI: 10.1093/eurjhf/hft037] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS This study was designed to evaluate a new NT-proBNP monitoring concept in outpatients with systolic heart failure (HF). METHODS AND RESULTS This was a multicentre, prospective randomized open-label blinded endpoint study. A total of 407 systolic HF patients were allocated to either clinical management (n = 208) or clinical management + NT-proBNP monitoring (n = 199) and followed for 2.5 years. If NT-proBNP increased >30%, a clinical checklist was completed and treatment initiated. The patients were matched at randomization and were 73 years old, 25% were females, 85% were NYHA class I-II, LVEF was 30%, and NT-proBNP 1955 pg/mL. NT-proBNP monitoring did not improve outcome, the hazard ratio for the primary composite endpoint (death or a cardiovascular admission) being 0.96 [95% confidence interval (CI) 0.71-1.29, P = 0.766]. NT-proBNP monitoring did not induce a significant change in the pharmacological strategy (P > 0.05 for all comparisons). In patients in whom NT-proBNP increased >30% (25% of the patients) during follow-up, a higher frequency of admission (69% vs. 47%, P = 0.002), a higher number of admission days (14 vs. 5 days, P = 0.003) and number of admissions (2 vs. 1, P = 0.009), and a lower quality of life (P = 0.032) and a poorer functional class (37% vs. 18% in NYHA class III-IV, P < 0.001) were observed. CONCLUSIONS Adding serial measurements of NT-proBNP to optimal clinical management was not associated with a change in pharmacological strategy and did not improve outcome. However, survivors in whom NT-proBNP increased >30% showed a poorer functional class, clinical outcome, and quality of life. TRIAL REGISTRATION www.centerwatch: 173491 (NorthStar).
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Luttik MLA, Brons M, Jaarsma T, Hillege HL, Hoes A, de Jong R, Linssen G, Lok DJ, Berger M, van Veldhuisen DJ. Design and methodology of the COACH-2 (Comparative study on guideline adherence and patient compliance in heart failure patients) study: HF clinics versus primary care in stable patients on optimal therapy. Neth Heart J 2012; 20:307-12. [PMID: 22527916 DOI: 10.1007/s12471-012-0284-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Since the number of heart failure (HF) patients is still growing and long-term treatment of HF patients is necessary, it is important to initiate effective ways for structural involvement of primary care services in HF management programs. However, evidence on whether and when patients can be referred back to be managed in primary care is lacking. AIM To determine whether long-term patient management in primary care, after initial optimisation of pharmacological and non-pharmacological treatment in a specialised HF clinic, is equally effective as long-term management in a specialised HF clinic in terms of guideline adherence and patient compliance. METHOD The study is designed as a randomised, controlled, non-inferiority trial. Two-hundred patients will be randomly assigned to be managed and followed in primary care or in a HFclinic. Patients are eligible to participate if they are (1) clinically stable, (2) optimally up-titrated on medication (according to ESC guidelines) and, (3) have received optimal education and counselling on pre-specified issues regarding HF and its treatment. Furthermore, close cooperation between secondary and primary care in terms of back referral to or consultation of the HF clinic will be provided.The primary outcome will be prescriber adherence and patient compliance with medication after 12 months. Secondary outcomes measures will be readmission rate, mortality, quality of life and patient compliance with other lifestyle changes. EXPECTED RESULTS The results of the study will add to the understanding of the role of primary care and HF clinics in the long-term follow-up of HF patients.
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Affiliation(s)
- M L A Luttik
- Department of Cardiology, University Medical Center Groningen, University of Groningen, PO BOX 30.001, 9700, RB, Groningen, the Netherlands,
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Schou M, Gustafsson F, Videbaek L, Tuxen C, Keller N, Handberg J, Sejr Knudsen A, Espersen G, Markenvard J, Egstrup K, Ulriksen H, Hildebrandt PR. Extended heart failure clinic follow-up in low-risk patients: a randomized clinical trial (NorthStar). Eur Heart J 2012; 34:432-42. [PMID: 22875412 DOI: 10.1093/eurheartj/ehs235] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Outpatient follow-up in specialized heart failure clinics (HFCs) is recommended by current guidelines and implemented in most European countries, but the optimal duration of HFC programmes has not been established. Nor is it known whether all or only high-risk patients, e.g. identified by NT-proBNP, might benefit from an extended HFC follow-up. METHODS AND RESULTS In a multi-centre setting, we randomly assigned 921 clinically stable systolic heart failure (HF) outpatients on optimal medical therapy to undergo either an extended follow-up in the HFC (n = 461) or referral back to their general practitioner (GP) (n = 460). The primary composite endpoint was death or a cardiovascular admission. Secondary endpoints included mortality, an HF admission, quality of life, number of days admitted, and number of admissions. The median age of the patients was 69 years; 23% were females; the median left ventricular ejection fraction was 0.30; and the median NT-proBNP was 801 pg/mL; 89% were in NYHA class I-II. The median follow-up was 2.5 years. Time-to-event did not differ between groups (HFC vs. GP) (HR: 1.17, 95% CI: 0.95-1.45, P = 0.149). The two groups did not differ with respect to any of the secondary endpoints at the follow-up (P> 0.05 for all). In high-risk patients identified by NT-proBNP ≥1000 pg/mL, no benefit from HFC follow-up was found (P = 0.721). CONCLUSION Irrespective of the level of NT-proBNP stable HF patients on optimal medical therapy do not benefit from long-term follow-up in a specialized HFC in a publicly funded universal access healthcare system. Heart failure patients on optimal medical therapy with mild or moderate symptoms are safely managed by their personal GP. TRIAL REGISTRATION www.Centerwatch.com: 173491 (NorthStar).
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Affiliation(s)
- Morten Schou
- Department of Cardiology and Endocrinology, Frederiksberg University Hospital, DK-2000 Frderiksberg, Denmark.
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Januzzi JL, Rehman SU, Mohammed AA, Bhardwaj A, Barajas L, Barajas J, Kim HN, Baggish AL, Weiner RB, Chen-Tournoux A, Marshall JE, Moore SA, Carlson WD, Lewis GD, Shin J, Sullivan D, Parks K, Wang TJ, Gregory SA, Uthamalingam S, Semigran MJ. Use of amino-terminal pro-B-type natriuretic peptide to guide outpatient therapy of patients with chronic left ventricular systolic dysfunction. J Am Coll Cardiol 2011; 58:1881-9. [PMID: 22018299 DOI: 10.1016/j.jacc.2011.03.072] [Citation(s) in RCA: 303] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 02/22/2011] [Accepted: 03/07/2011] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether chronic heart failure (HF) therapy guided by concentrations of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) is superior to standard of care (SOC) management. BACKGROUND It is unclear whether standard HF treatment plus a goal of reducing NT-proBNP concentrations improves outcomes compared with standard management alone. METHODS In a prospective single-center trial, 151 subjects with HF due to left ventricular (LV) systolic dysfunction were randomized to receive either standard HF care plus a goal to reduce NT-proBNP concentrations ≤1,000 pg/ml or SOC management. The primary endpoint was total cardiovascular events between groups compared using generalized estimating equations. Secondary endpoints included effects of NT-proBNP-guided care on patient quality of life as well as cardiac structure and function, assessed with echocardiography. RESULTS Through a mean follow-up period of 10 ± 3 months, a significant reduction in the primary endpoint of total cardiovascular events was seen in the NT-proBNP arm compared with SOC (58 events vs. 100 events, p = 0.009; logistic odds for events 0.44, p = 0.02); Kaplan-Meier curves demonstrated significant differences in time to first event, favoring NT-proBNP-guided care (p = 0.03). No age interaction was found, with elderly patients benefitting similarly from NT-proBNP-guided care as younger subjects. Compared with SOC, NT-proBNP-guided patients had greater improvements in quality of life, demonstrated greater relative improvements in LV ejection fraction, and had more significant improvements in both LV end-systolic and -diastolic volume indexes. CONCLUSIONS In patients with HF due to LV systolic dysfunction, NT-proBNP-guided therapy was superior to SOC, with reduced event rates, improved quality of life, and favorable effects on cardiac remodeling. (Use of NT-proBNP Testing to Guide Heart Failure Therapy in the Outpatient Setting; NCT00351390).
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Affiliation(s)
- James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Pandit K, Mukhopadhyay P, Ghosh S, Chowdhury S. Natriuretic peptides: Diagnostic and therapeutic use. Indian J Endocrinol Metab 2011; 15 Suppl 4:S345-S353. [PMID: 22145138 PMCID: PMC3230091 DOI: 10.4103/2230-8210.86978] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Natriuretic peptides (NPs) are hormones which are mainly secreted from heart and have important natriuretic and kaliuretic properties. There are four different groups NPs identified till date [atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP), C-type natriuretic peptide (CNP) and dendroaspis natriuretic peptide, a D-type natriuretic peptide (DNP)], each with its own characteristic functions. The N-terminal part of the prohormone of BNP, NT-proBNP, is secreted alongside BNP and has been documented to have important diagnostic value in heart failure. NPs or their fragments have been subjected to scientific observation for their diagnostic value and this has yielded important epidemiological data for interpretation. However, little progress has been made in harnessing the therapeutic potential of these cardiac hormones.
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Affiliation(s)
- Kaushik Pandit
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research and S.S.K.M. Hospital, Kolkata, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research and S.S.K.M. Hospital, Kolkata, India
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research and S.S.K.M. Hospital, Kolkata, India
| | - Subhankar Chowdhury
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research and S.S.K.M. Hospital, Kolkata, India
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Troughton RW, Nicholls MG. B-type natriuretic peptide or amino-terminal pro-B-type natriuretic peptide-guided treatment of heart failure: what is the next STEP? Eur J Heart Fail 2011; 13:1046-8. [PMID: 21873341 DOI: 10.1093/eurjhf/hfr117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Troughton RW, Lewis LK, Yandle TG, Pemberton CJ, Nicholls MG. B-type natriuretic peptides: looking to the future. Ann Med 2011; 43:188-97. [PMID: 20961274 DOI: 10.3109/07853890.2010.526630] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Whereas the role of the cardiac natriuretic peptides, ANP and BNP, in some aspects of physiology and pathophysiology is clear, their potential in diagnosis, prognosis, and therapeutics in many clinical disorders remains uncertain. We predict that circulating levels of these peptides will find increasing diagnostic utility in patients presenting with dyspnoea, in guiding the complex pharmacotherapy in heart failure, and may likewise be useful in guiding the management of patients on chronic maintenance renal dialysis. We predict also that levels of these peptides will be of practical use as prognostic indicators in 'at-risk' populations (such as those with diabetes, coronary heart disease, hypertension, thalassaemia, etc.) but probably not in the general population. It appears likely that administration of these peptides will find a place in the therapeutics of acute myocardial infarction, but this is less clear for heart failure. We describe the presence of a segment of the signal peptide for BNP within the circulation and discuss its potential clinical utility.
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Affiliation(s)
- Richard W Troughton
- Department of Medicine, University of Otago Christchurch, Christchurch Hospital, Christchurch, New Zealand
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Baibars M, Ibrahim A, Fang JC, Sipahi I. Natriuretic peptide-guided management of patients with heart failure: a decade of progress but still a controversy. Future Cardiol 2011; 6:743-7. [PMID: 21142628 DOI: 10.2217/fca.10.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Goei D, van Kuijk JP, Flu WJ, Hoeks SE, Chonchol M, Verhagen HJ, Bax JJ, Poldermans D. Usefulness of Repeated N-Terminal Pro-B-Type Natriuretic Peptide Measurements as Incremental Predictor for Long-Term Cardiovascular Outcome After Vascular Surgery. Am J Cardiol 2011; 107:609-14. [DOI: 10.1016/j.amjcard.2010.10.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 10/05/2010] [Accepted: 10/05/2010] [Indexed: 11/15/2022]
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Kim HN, Januzzi JL. Biomarkers in the Management of Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 12:519-31. [DOI: 10.1007/s11936-010-0096-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bhardwaj A, Rehman SU, Mohammed A, Baggish AL, Moore SA, Januzzi JL. Design and methods of the Pro-B Type Natriuretic Peptide Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study. Am Heart J 2010; 159:532-538.e1. [PMID: 20362709 DOI: 10.1016/j.ahj.2010.01.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 01/07/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Serial measurements of N-terminal pro-B type natriuretic peptide (NT-proBNP) provide prognostic information in patients with chronic heart failure (HF). Changes in NT-proBNP concentrations parallel prognosis; however, it remains unclear whether HF care with a goal to maximize medical therapy and also lower NT-proBNP concentrations is superior to standard HF care alone. AIMS The aim of the study was to evaluate the hypothesis that an HF strategy guided by NT-proBNP reduces cardiovascular events compared to standard of care HF management. METHODS In a prospective randomized single-center trial, subjects with New York Heart Association class II to IV systolic HF (left ventricular ejection fraction < or =40%) will be enrolled. Both groups will receive standard HF management (with a goal for minimizing HF symptoms and achieving maximal dosages of therapies with proven mortality benefit in HF), whereas one group ("NT-proBNP") will also have treatment adjustments to reduce NT-proBNP concentrations < or =1,000 pg/mL. The primary end point of the trial is total cardiovascular events for a 1-year period; secondary end points will include effects of NT-proBNP-guided care on cardiac structure and function, quality of life, and total costs of care. RESULTS Enrollment began in 2006; of the original 300 planned, thus far, 151 subjects have been randomized. Interim analysis in November 2009 indicated significant reduction of events in the NT-proBNP arm. Full results are expected in 2010. CONCLUSIONS The Pro-B Type Natriuretic Peptide Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study will test the hypothesis that therapy guided by NT-proBNP concentrations will be superior to standard of care HF management (www.clinicaltrials.gov identifier NCT00351390).
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N-terminal pro-B-type natriuretic peptide-guided, intensive patient management in addition to multidisciplinary care in chronic heart failure a 3-arm, prospective, randomized pilot study. J Am Coll Cardiol 2010; 55:645-53. [PMID: 20170790 DOI: 10.1016/j.jacc.2009.08.078] [Citation(s) in RCA: 221] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 07/06/2009] [Accepted: 08/31/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study was designed to investigate whether the addition of N-terminal pro-B-type natriuretic peptide-guided, intensive patient management (BM) to multidisciplinary care (MC) improves outcome in patients following hospitalization due to heart failure (HF). BACKGROUND Patients hospitalized due to HF experience frequent rehospitalizations and high mortality. METHODS Patients hospitalized due to HF were randomized to BM, MC, or usual care (UC). Multidisciplinary care included 2 consultations from an HF specialist who provided therapeutic recommendations and home care by a specialized HF nurse. In addition, BM included intensified up-titration of medication by HF specialists in high-risk patients. NT-proBNP was used to define the level of risk and to monitor wall stress. This monitoring allowed for anticipation of cardiac decompensation and adjustment of medication in advance. RESULTS A total of 278 patients were randomized in 8 Viennese hospitals. After 12 months, the BM group had the highest proportion of antineurohormonal triple-therapy (difference among all groups). Accordingly, BM reduced days of HF hospitalization (488 days) compared with the hospitalization for the MC (1,254 days) and UC (1,588 days) groups (p < 0.0001; significant differences among all groups). Using Kaplan-Meier analysis, the first HF rehospitalization (28%) was lower in the BM versus MC groups (40%; p = 0.06) and the MC versus UC groups (61%; p = 0.01). Moreover, the combined end point of death or HF rehospitalization was lower in the BM (37%) than in the MC group (50%; p < 0.05) and in the MC than in the UC group (65%; p = 0.04). Death rate was similar between the BM (22%) and MC groups (22%), but was lower compared with the UC group (39%; vs. BM: p < 0.02; vs. MC: p < 0.02). CONCLUSIONS Compared with MC alone, additional BM improves clinical outcome in patients after HF hospitalization. (BNP Guided Care in Addition to Multidisciplinary Care; NCT00355017).
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Adams KF, Felker GM, Fraij G, Patterson JH, O'Connor CM. Biomarker guided therapy for heart failure: focus on natriuretic peptides. Heart Fail Rev 2009; 15:351-70. [PMID: 19377882 DOI: 10.1007/s10741-009-9139-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kirkwood F Adams
- Department of Medicine, School of Medicine, UNC Heart Failure Program, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA.
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Gustafsson F, Schou M, Videbaek L, Dridi N, Ryde H, Handberg J, Hildebrandt PR. Incidence and predictors of hospitalization or death in patients managed in multidisciplinary heart failure clinics. Eur J Heart Fail 2009; 11:413-9. [DOI: 10.1093/eurjhf/hfp025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Finn Gustafsson
- Department of Cardiology B; The Heart Centre, Rigshospitalet; Blegdamsvej 9 DK-2100 Copenhagen Denmark
| | - Morten Schou
- Department of Cardiology and Endocrinology; Frederiksberg Hospital; Frederiksberg Denmark
| | - Lars Videbaek
- Department of Cardiology; Odense University Hospital; Odense Denmark
| | - Nadia Dridi
- Department of Internal Medicine; Amager Hospital; Copenhagen Denmark
| | - Henrik Ryde
- Department of Internal Medicine; Slagelse Sygehus; Slagelse Denmark
| | - Jens Handberg
- Department of Cardiology and Endocrinology Hillerød Sygehus; Hillerød Denmark
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